Update on management of HYPERTENSION BMH-GT 12/03/08

1. Update on management of HYPERTENSION BMH-GT 12/03/08 Panelists : All Internists and medical staff members are welcome to participate in discussion

2. Hypertension: A Significant CV and Renal Disease Risk Factor CAD CHF LVH Stroke Hypertension Renal disease  Morbidity  Disability Peripheral vascular disease National High Blood Pressure Education Program Working Group. Arch Intern Med. 1993;153:186-208.

3. Blood Pressure ClassificationJNC VII

4. Compelling Indications for Individual Drug Classes

5. Compelling Indications for Individual Drug Classes

6. JNC-VII New Features and Key Messages (Continued) • Thiazide-type diuretics should be initial drug therapy for most, either alone or combined with other drug classes. • Certain high-risk conditions are compelling indications for other drug classes. • Most patients will require two or more antihypertensive drugs to achieve goal BP. • If BP is >20/10 mmHg above goal, initiate therapy with two agents, one usually should be a thiazide-type diuretic.

7. New Features and Key Messages • For persons over age 50, SBP is a more important than DBP as CVD risk factor • Starting at 115/75 mmHg, CVD risk doubles with each increment of 20/10 mmHg throughout the BP range. • Persons who are normotensive at age 55 have a 90% lifetime risk for developing HTN. • Those with SBP 120–139 mmHg or DBP 80–89 mmHg should be considered prehypertensive who require health-promoting lifestyle modifications to prevent CVD.

8. Algorithm for Treatment of Hypertension Without Compelling Indications With Compelling Indications Drug(s) for the compelling indications Other antihypertensive drugs (diuretics, ACEI, ARB, BB, CCB) as needed. Stage 1 Hypertension(SBP 140–159 or DBP 90–99 mmHg) Thiazide-type diuretics for most. May consider ACEI, ARB, BB, CCB, or combination. Stage 2 Hypertension(SBP >160 or DBP >100 mmHg) 2-drug combination for most (usually thiazide-type diuretic and ACEI, or ARB, or BB, or CCB) Not at Goal Blood Pressure Optimize dosages or add additional drugs until goal blood pressure is achieved.Consider consultation with hypertension specialist. Lifestyle Modifications Not at Goal Blood Pressure (<140/90 mmHg) (<130/80 mmHg for those with diabetes or chronic kidney disease) Initial Drug Choices 8

9. Guidelines on Management of Diabetic Nephropathy • Hypertensive Type 2 Diabetic Patients* • ARBs are the initial agents of choice • Type 1 Diabetics with or without hypertension* • ACEIs are the initial agents of choice • African Americans demonstrate somewhat reduced BP responses to monotherapy with BBs, ACEIs, or ARBs compared to diuretics or CCBs. • These differences usually eliminated by adding adequate doses of a diuretic

10. LVH • Prevalent in children with obesity as well • LVH is an independent risk factor that increases the risk of CVD. • Regression of LVH occurs with aggressive BP management: weight loss, sodium restriction, and treatment with all classes of drugs except the direct vasodilators hydralazine and minoxidil.

11. Hypertension in Elderly • Hypertension is common. • SBP is a better predictor of events than DBP. • Pseudohypertension and “white-coat hypertension” may indicate a need for readings outside the office. • Primary hypertension is the most common cause, but common identifiable causes (e.g., renovascular hypertension) should be considered

12. Management in Elderly • Most prevalent and least controlled • Lower initial drug doses may be indicated to avoid symptoms; standard doses and multiple drugs will be needed to reach BP targets. • Avoid volume depletion and excessively rapid dose titration of drugs.

13. Special Situations • Pregnancy use Aldomet ;hydralazine ;Labetolol (ACEI contraindicated) Nipride (<4hours) • Asthma and CHF patients • Labetolol ( iV or PO) • Carvedilol • Nevibolol

14. One size doesn’t fit all • Attack sympathetic tone (clonidine max 0.6 mg patch ) • Use direct vasodilation (Hydralazine ; minoxdil) • Reserpine depletes catecholamines • Diuretics in different isolated doses • CCB or ACEI/ARB depending on special needs

15. BP controls Depends on 3 • Volume Status • Autonomic reflexes ( sympathetic tone) • Renin –angiotensin system

16. Sympatholytics • Alpha or Beta Blockers • Clonidine • Reserpine • Phentolamine

17. RAS SYSTEM MEDs. • ACEI • ARB • DRI • BETA BLOCKERS

18. 2nd Tier medicines • Clonidine ( patch is still expensive)--central • Minoxidil black box warning ; direct peripheral vasodialtor ( edema and tachy) • Cardura - alpha 1 blocker --CHF ; edema (apply to all alpha blockers) • Reserpine –preipheral adrenergic inhibitor-depression • Hydralazine ---bidil direct vasodilator

19. Diuretics Therapy • HCTZ is underdosed in Combination pills • MRFIT, ALLHAT show Chlorthalidone is superior. Chlor-clonidine combination • Aldosterone –12 mmHg in resistant HTN, LVH, Endothelial fn; Inspra is generic • Stage 4 to Stage 5 CKD use demadex which is generic now (less hypokalemia than HCTZ and equal BP reduction)

20. CCB Therapy • Non-Dihydropyridines Nifedipine,Diltiazem • Dihydropyridines DHP(Norvasc, PLendil) • Nisoldipine most cardioselective • Non-DHP reduce proteinuria • Combination is more potent • Pulm.HTN; PVD; Arrythmias; LVH • Edema worse with DHP

21. Dietary Approaches to Stop Hypertension (DASH) • Diet high in fruits and vegetables and low-fat dairy products lowers blood pressure (11 mmHg SBP/ 5 mmHg DBP lower than traditional US diet), including more than a sodium-restricted diet • Recommends 7-8 servings/day of grain/grain products, 4-5 vegetable, 4-5 fruit, 2-3 low- or non-fat dairy products, 2 or less meat, poultry, and fish. • NEJM 1997; 366: 1117-24.

22. www.nhlbi.nih.gov/

23. Causes of Resistant Hypertension • Improper BP measurement • Excess sodium intake • Inadequate diuretic therapy • Medication • Inadequate doses • Drug actions and interactions (e.g., nonsteroidal anti-inflammatory drugs (NSAIDs), illicit drugs, sympathomimetics, oral contraceptives) • Over-the-counter (OTC) drugs and herbal supplements • Excess alcohol intake • Identifiable causes of HTN

24. Lose weight if overweight Limit alcohol intake Increase aerobic physical activity Reduce sodium intake Maintain adequate intake of potassium Maintain adequate intake of calcium and magnesium Stop smoking Reduce dietary saturated fat and cholesterol Lifestyle Modifications For Prevention and Management For Overall and Cardiovascular Health

25. Lifestyle Modification

26. NON-PHARMACOLOGIC MEASURES • SLEEP APNEA • EXERCISE • ALCOHOL • DIET; K INTAKE; SODIUM • AMBULATORY BP MONITORING • RESPERATE BIOFEEDBACK • SECONDARY HTN